Journal Article > Study

This study identified 100 cases of diagnostic error in internal medicine and conducted retrospective chart reviews and interviews to determine what role systems-related and cognitive factors played. Investigators discovered nearly six independent factors per case and provide a detailed discussion of the most common findings. These include system-related problems such as inefficient processes and cognitive problems such as failure to consider alternative clinical diagnoses. The authors propose a classification system for the factors that produce errors and offer a number of strategies to reduce their incidence.

Journal Article > Study

This commentary discusses the increasing recognition of diagnostic errors, the limited research to understand and prevent them, and an approach from aviation that may further those efforts. The authors begin with a general discussion about diagnostic errors before presenting a framework for situational awareness—a model developed in aviation that focuses on decision making. Using a case example, the authors illustrate how situational awareness can be applied to health care settings by asking fundamental questions that incorporate a cognitive approach with a systems approach. They advocate for greater study of this approach in patient care, realizing that many of the advantages are also met with limitations in translating it from aviation. A past study evaluated 100 cases of diagnostic error to similarly describe the contributions of system-related problems versus cognitive ones.